The American College of Surgeons (ACS) requires trauma centers to provide a brief intervention to patients who have screened positive for alcohol misuse. However, many programs find it difficult to build a truly effective Screening, Brief Intervention and Referral to Treatment (SBIRT) process.
Trauma leaders at Franciscan Health Crown Point in Crown Point, Indiana, tackled this challenge by creating an enhanced SBIRT team that rounds daily on patients who screen positive for alcohol or drug use. This initiative earned the team the 2023 Peregrine Award for Trauma Innovation in the “Level III, IV or V Trauma Centers” category.
Franciscan Health’s winning innovation was submitted by Jennifer Homan, RN, MSN, CPTI, the hospital’s manager of trauma and injury prevention.
Fragmented process, high complications
Data showed that a large portion of Franciscan Health’s patient population suffer from alcohol use disorder (AUD) or substance use disorder (SUD). Trauma leaders wanted to improve long-term outcomes for these patients and reduce readmissions.
“While we had an SBIRT process for our trauma patients, we seemed to fall short in getting people the help they needed once they were discharged,” Homan explained.
The hospital’s SBIRT process consisted of using the AUDIT-C tool. However, follow-up processes were fragmented and the EMR was not optimized for the SBIRT workflow: “The screening scores were not easily calculated in the flowsheet,” Homan said, “so when the screening was completed, little was done with the information.”
TQIP reports indicated higher than average complication rates that resulted from complicates due to alcohol withdrawal. “These included unplanned admissions to the ICU and unplanned intubations,” Homan explained. “This was identified as an opportunity for process improvement.”
Team-based approach
The team’s first step was to secure additional funding. Homan applied for and received a $125,000 annual grant from ECHO, a State of Indiana program aimed at reducing overdose deaths.
The trauma program used that money to hire a licensed social worker (1.0 FTE) and a peer recovery coach (0.7 FTE) to form the core of the substance use team. The grant also enabled Homan to increase the trauma program’s half-time injury prevention coordinator to a full-time employee.
As part of the planning process, Homan created an 12-question online survey to evaluate the organization’s current knowledge and comfort with screening for substance use disorders, assessing and managing withdrawal, and discussing recovery. This enabled trauma leaders to identity priority educational opportunities for the entire healthcare team.
With a substance use team in place and educational goals identified, trauma designed and implemented a new SBIRT process in February 2022. The new process is:
1. Identify patients who have substance use disorders in the ED or inpatient units. The substance use team utilizes trauma lists and EMR reports to identify patients who screen positive for AUD or SUD. Screening is driven by the primary medical team’s review of medical and social history and/or urine drug screens and ETOH levels. If the medical history or labs are positive for AUD or SUD, a consult to crisis for treatment is implemented.
“A consult to crisis for SUD/AUD order was developed in the EMR and a policy was created that allows any member of the healthcare team to consult the team for the SBIRT process,” Homan explained.
2. Social worker/peer recovery coach complete the SBIRT process. During the crisis consult, the social worker readministers the DAST and AUDIT-C screening.
“Intervention is completed during the assessment by the social worker or the recovery coach on patients that have a positive screening or assessment,” Homan explained.
The hospital’s crisis consult policy also allows telephone evaluation for any patient who was discharged prior to evaluation by the crisis team.
3. Round on inpatients with substance use disorders daily. The recovery coach and social worker round daily to complete the SBIRT as needed and begin recovery conversations with patients who score high on their AUDIT-C or DAST screenings. Discussions touch on peer support, harm reduction and other personal recovery strategies.
Significantly, the recovery coach is a certified addiction counselor who has personal experience of addiction. This background enables her to reach patients who previously have not been open to discussing their substance or alcohol use disorder.
4. Arrange treatment after discharge. The team ensures that patients with AUD or SUD are receiving appropriate treatment and/or therapy while they are in the hospital. They also work to ensure patients receive recovery care after discharge.
“If the patient is ready, we will make the appointment and even arrange transportation to the next level of care,” Homan said. “Hopefully by the time they move out of the hospital, we are ready to get them to move into recovery.”
5. Provide education on harm reduction to patients and families. In addition to coaching patients on personal recovery strategies, the team provides patients with harm reduction strategies such as Narcan training for overdose.
Real-world results
The reworked SBIRT process has led to improved intervention and referral rates. According to Homan:
- In 2022, Franciscan Health Crown Point screened approximately 890 patients for AUD/SUD, and about 525 (59%) of these patients screened positive.
- Of the patients who screened positive, the trauma social worker or peer recovery coach were able to follow up with 498 patients (approximately 95%).
- Of the patients who screened positive and connected with the substance use team, 54% were referred to either inpatient or outpatient SUD/AUD treatment post discharge.
“Our Level III trauma program took an old standard and was able to find flaws in the current process,” Homan explained. “With a little innovation, we were able to reinvent the process with just a small investment in human capital.”
Learn more
Homan believes it is important for trauma centers to treat patients both physically and psychologically to reduce the risk of future trauma or health disorders.
“Because of the stigma of having an alcohol or substance use disorder, patients may be unwilling to seek treatment on their own,” she said. “When we develop ongoing therapeutic conversations during their stay, we have a greater chance of improving their future.”
Homan discussed her team’s new SBIRT process in detail during the May 2023 online event honoring the winners of the Peregrine Award for Trauma Innovation. To view the webinar on-demand, visit Profiles in Trauma Innovation: Improving PIPS and SBIRT.